Faster diagnosis key to finding drug-resistant tuberculosis in the Republic of Moldova

March 2014

Cristina had been sick with pneumonia-like symptoms for three months. She kept putting off going to the doctor, hoping that she could cure her illness with herbal treatments at home.

Even though her health insurance covers the cost of most health services, Cristina, who is in her seventies, was worried about the additional costs of going to hospital. “You have to prepare for it by saving money for transportation, and food and clothes to take with you,” she says.

Eventually when she was “nearly dead”, she says, she went to the doctor who diagnosed her with tuberculosis (TB) and transferred her to hospital in Chisinau. She then spent 6 weeks in the TB ward before she was eventually diagnosed with multidrug-resistant TB (MDR-TB).

“Rapid diagnosis is extremely important in combating MDR-TB,” says Dr Pierpaolo de Colombani from the review team of the national TB programme organized by the WHO Regional Office for Europe. For too many people, however, diagnosis comes late, or, not at all. WHO estimates that just one in four new MDR-TB cases were diagnosed in 2012.

High burden of MDR-TB

Diagnosing TB in Moldova
PAS Center/Valeriu Crudu

The Republic of Moldova is among the WHO European Region’s 18 high-priority countries for TB control and one of the world’s 27 countries with the highest burden of MDR-TB.

Almost one third of people newly diagnosed with TB in the Republic of Moldova, and two thirds of those returning for treatment, have MDR-TB. Significant ongoing transmission is due to many factors including unjustified and lengthy hospital stays, poor infection control in TB hospitals, poverty and poor living conditions and late diagnosis.

Rolling out new diagnostic tools

As part of key recommendations made by WHO to combat drug-resistant TB, the Republic of Moldova is introducing rapid diagnostic tools for MDR-TB at the point-of-care. Since 2012, Xpert MTB/RIF assay units have been installed in 30 district and municipal TB services across the country.

Xpert MTB/RIF assay is a rapid, accurate test that can detect TB infection and resistance to the antibiotic rifampicin in less than 2 hours. Unlike traditional smear microscopy, this test can be done outside conventional laboratories and does not require any special training.

If Xpert MTB/RIF assay had been available for Cristina, she would have had the right diagnosis in days, not weeks. She would then have been started immediately on appropriate treatment, giving her a better chance of recovery and reducing the risk of cross-infection or infecting others as well.

“Xpert MTB/RIF has expanded access to testing and decreased delays in diagnosis, without the need to build large numbers of laboratories with advanced biosafety requirements,” says Dr Elena Romancenco, head of the National Reference TB Laboratory in Chisinau.

Reaching high-risk populations

Last year, the tool was also made available at all sites where people receive antiretroviral therapy for HIV treatment, including the Transnistrian Region and in prison hospitals where both HIV and TB rates are higher than the rest of the country.

“Rapid diagnosis is extremely important in combating MDR-TB.”

Dr Pierpaolo de Colombani, from the TBM programme, WHO Regional Office for Europe

“Given the nature of TB evolution in people living with HIV, Xpert MTB/RIF is contributing a lot to rapid diagnosis of TB, considerably shortening the stay of these patients with other immuno-compromised patients at antiretroviral therapy sites,” says Dr Lucia Pirtina, national HIV programme manager, and deputy director of the National Hospital for Dermatology and Communicable Diseases.

Nongovernmental organization, Act for Involvement, is also seeing the direct benefits of this new technology in speeding up diagnosis in high-risk populations such as homeless people and prison inmates. “This tool has cut the lead time on lab results, making it possible to enrol people in treatment right away,” says Lilian Severin, director of Act for Involvement.

Paying for the project

Funding for the initial roll-out of Xpert MTB/RIF was secured through a global 27-country project called EXPAND-TB (Expanding Access to New Diagnostics for TB), funded by UNITAID, as well as the TB REACH initiative funded by the Canadian Government.

The EXPAND-TB project also played a critical role in boosting capacity in the national reference laboratory and two regional reference laboratories to support the implementation of Xpert MTB/RIF assay.

Dr Jarno Habicht, WHO representative in the Republic of Moldova, says a major challenge will be sustaining the system with domestic funds in the years to come: “Given the tight public budgets and the need to prioritize across different competing health needs, as well as the eventual graduation of Moldova from Global Fund eligibility, we need to find feasible solutions on how to ensure sustainable access to essential technologies and resources to decrease the TB burden across the country.”

In the meantime, the national TB programme is achieving significant success in increasing access to rapid diagnostic tools across the country, particularly for primary diagnosis of TB, enabling people like Cristina to get the care that they need much faster.